Australian Government s5

Australian Government

Department of Health

Medicare Benefits Schedule Book

Optometrical Services

Schedule

Operating from 1 May 2016

ISBN: 978-1-76007-227-8

Online ISBN: 978-1-76007-228-5

Publications approval number: 11292

Paper-based publications

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This work is copyright. You may download, display, print and reproduce the whole or part of this work in unaltered form for your own personal use or, if you are part of an organisation, for internal use within your organisation, but only if you or your organisation do not use the reproduction for any commercial purpose and retain this copyright notice and all disclaimer notices as part of that reproduction. Apart from rights to use as permitted by the Copyright Act 1968 or allowed by this copyright notice, all other rights are reserved and you are not allowed to reproduce the whole or any part of this work in any way (electronic or otherwise) without first being given the specific written permission from the Commonwealth to do so. Requests and inquiries concerning reproduction and rights are to be sent to the Communication Branch, Department of Health, GPOBox 9848, Canberra ACT 2601, or via e-mail to .

At the time of printing, the relevant legislation giving authority for the changes included in this edition of the book may still be subject to the approval of Executive Council and the usual Parliamentary scrutiny. This book is not a legal document, and, in cases of discrepancy, the legislation will be the source document for payment of Medicare benefits.

INTRODUCTION

This book provides information on the arrangements for the payment of Medicare benefits for optometric services by optometrists.

Part 1 of this book contains an outline of the arrangements for optometric benefits and notes for the guidance of optometrists, including addresses of the Department of Health and the Department of Human Services. Further information on the Medicare Benefits Schedule (MBS) can be located at www.mbsonline.gov.au.

The Schedule in Part 2 shows the item number, description of service, Schedule fee and Medicare benefit payable in respect of the optometric items.

CHANGES INCLUDED IN THIS EDITION

There are no changes in this edition.

CONTENTS

PART 1 - OUTLINE OF ARRANGEMENTS AND NOTES FOR GUIDANCE 6

O.1. BENEFITS FOR SERVICES 7

O.2. PROVIDER NUMBERS 7

O.3. PATIENT ELIGIBILITY 7

O.4. BENEFITS FOR OPTOMETRISTS 8

O.5. SCHEDULE FEES AND MEDICARE BENEFITS 10

O.6. BILLING PROCEDURES 16

O.7. REFERRALS 20

O.8. PROVISION FOR REVIEW OF THE SCHEDULE Error! Bookmark not defined.

O.9. FOR REVIEW OF PRACTITIONER BEHAVIOUR 22

O.10. VISITING OPTOMETRISTS SCHEME (VOS) 24

O.11. TELEHEALTH PATIENT-END SUPPORT SERVICES BY OPTOMETRISTS 24

COMMONWEALTH DEPARTMENT OF HEALTH 27

COMMONWEALTH DEPARTMENT OF HUMAN SERVICES 27

PART 2 - SCHEDULE OF SERVICES 28

GROUP A10 - OPTOMETRICAL SERVICES 29

SUBGROUP 1 – GENERAL 29

GROUP A10 - OPTOMETRICAL SERVICES 35

SUBGROUP 2 – TELEHEALTH ATTENDANCE 35

PART 1 - OUTLINE OF ARRANGEMENTS AND NOTES FOR GUIDANCE

O.1. BENEFITS FOR SERVICES

All Australian residents and certain categories of visitors to Australia can claim Medicare benefits for services by optometrists. The Health Insurance Act 1973 contains legislation covering the major elements of the Medicare program.

Responsibility for regulating the Medicare program lies with the Australian Government through the Department of Health. The Department of Human Services is responsible for consideration of applications and for the day to day operation of Medicare and the payment of benefits. Contact details of the Department of Health and the Department of Human Services are located at the end of these Notes.

O.2. PROVIDER NUMBERS

To ensure that benefits are paid only for services provided by optometrists registered with the Optometry Board of Australia, each optometrist providing services for which a Medicare benefit is payable requires an individual provider number.

Provider numbers will be issued only to registered optometrists. Corporations, other business entities and individuals who are not registered optometrists will not be issued with provider numbers.

Provider numbers are allocated to enable claims for Medicare benefits to be processed. The number may be up to eight characters. The second last character identifies the practice location, the last being a check character.

Optometrists can obtain a provider number from the Department of Human Services. A separate provider number is issued for each location at which an optometrist practises and has current registration. Provider numbers for additional practice locations may also be obtained from the Department of Human Services following confirmation of registration. Optometrists cannot use another optometrist's provider number.

Locum Tenens

An optometrist who is to provide services at a practice location as a locum for more than two weeks or will return to the practice on a regular basis for short periods should apply for a provider number for that location.

If the locum is to provide services at a practice for less than two weeks, the locum can use their own provider number or can obtain an additional provider number for that location.

Normally, Medicare benefits are payable for services rendered by an optometrist. .

To ensure benefits are payable when a locum practises in these circumstances, the locum optometrist should:

· Check that they will be providing optometry services on behalf of an optometrist; and

· Complete the Schedule which is available on the Department of Human Services website http://www.humanservices.gov.au/, before commencing the locum arrangement of the name and address of the optometrist on whose behalf they will be providing services.

Locums can direct Medicare payments to a third party, for example the principal of the practice, by either arranging a pay group link and/or by nominating the principal as the payee provider on bulk-bill stationery.

O.3. PATIENT ELIGIBILITY

An "eligible person" is a person who resides permanently in Australia. This includes New Zealand citizens and holders of permanent residence visas. Applicants for permanent residence may also be eligible persons, depending on circumstances. Eligible persons must enrol with Medicare before they can receive Medicare benefits.

Medicare covers services provided only in Australia. It does not refund treatment or evacuation expenses overseas.

Medicare Cards

The green Medicare card is for people permanently in Australia. Cards may be issued for individuals or families.

The blue Medicare card bearing the words “INTERIM CARD” is for people who have applied for permanent residence.

Visitors from countries with which Australia has a Reciprocal Health Care Agreement (RHCA) receive a card bearing the words "RECIPROCAL HEALTH CARE".

Visitors to Australia and temporary residents

Visitors and temporary residents in Australia are generally not eligible for Medicare and should therefore have adequate private health insurance.

Reciprocal Health Care Agreements

Australia has RHCAs with New Zealand, Ireland, the United Kingdom, the Netherlands, Sweden, Finland, Norway, Italy, Belgium, Slovenia and Malta.

Visitors from these countries are entitled to medical treatment while they are in Australia, comprising public hospital care (as public patients), Medicare benefits for out of hospital services and drugs under the Pharmaceutical Benefits Scheme (PBS). Visitors must enrol with the Department of Human Services to receive benefits. A passport is sufficient for public hospital care and PBS drugs.

Exceptions:

· Visitors from Ireland and New Zealand are entitled to public hospital care and PBS drugs only, and should present their passports before treatment as they are not issued with Medicare cards.

· Visitors from Italy and Malta are covered for a period of six (6) months only.

The RHCAs do not cover treatment as a private patient in a public or private hospital. People visiting Australia for the purpose of receiving treatment are not covered. Visitors from New Zealand and the Republic of Ireland are NOT entitled to optometric treatment under a RHCA.

O.4. BENEFITS FOR OPTOMETRISTS

What services are covered?

The Health Insurance Act 1973 stipulates that Medicare benefits are payable for professional services. The professional services coming within the scope of the optometric benefit arrangements are those clinically relevant services ordinarily rendered by the optometrist in relation to a consultation on ocular or vision problems or related procedures. The Health Insurance Act 1973 defines a ‘clinically relevant service’ as a service rendered by an optometrist that is generally accepted in the optometrical profession as being necessary for the appropriate treatment of the patient to whom it is rendered.

Since 1 January 2015 optometrists have been able to set their own fees for their professional services. However, the amount specified in the patient’s account must be the amount charged for the service specified. The fee may not include a cost of goods or services which are not part of the MBS service specified on the account. A non-clinically relevant service must not be included in the charge for a Medicare item. The non-clinically relevant service must be separately listed on the account and not billed to Medicare. Where it is necessary for the optometrist to seek patient information from the Department of Human Services in order to determine appropriate itemisation of accounts, receipts or bulk-billed claims, the optometrist must ensure that:

(a) the patient is advised of the need to seek the information and the reason the information is required;

(b) the patient's informed consent to the release of information has been obtained; and

Benefits may only be claimed when:

(a) a service has been performed and a clinical record of the service has been made;

(b) a significant consultation or examination procedure has been carried out;

(d) the service is "clinically relevant" (as defined in the Health Insurance Act 1973).

Where Medicare benefits are not payable

Medicare benefits may not be claimed for attendances for:

(a) delivery, dispensing, adjustment or repairs of visual aids;

(b) filling of prescriptions written by other practitioners.

Benefits are not payable for optometry services associated with:

(a) cosmetic surgery;

(b) refractive surgery;

(d) compulsory examinations or tests to obtain any commercial licence (e.g. flying or driving);

(e) entrance to schools or other educational facilities;

(f) compulsory examinations for admissions to aged care facilities; and

(g) vision screening.

Medicare benefits are not payable for services in the following circumstances:

(a) where the expenses for the service are paid or payable to a recognised (public) hospital;

(b) an attendance on behalf of teaching institutions on patients of supervised students of optometry; and

Unless the Minister otherwise directs, a benefit is not payable in respect of an optometric service where:

(a) the service has been rendered by or on behalf of, or under an arrangement with, the Commonwealth, a State or a local governing body or an authority established by a law of the Commonwealth, a law of a State or a law of an internal Territory; or

(b) the service was rendered in one or more of the following circumstances –

(i) the employer arranges or requests the consultation;

(ii) the results are provided to the employer by the optometrist;

(iii) the employer requires that the employee have their eyes examined;

(iv) the account for the consultation is sent to the employer; or

(v) the consultation takes place at the patient's workplace or in a mobile consulting room at the patient's workplace.

Services rendered to an optometrist's dependants, employer or practice partner or dependants

The optometrist agrees not to submit an account or claim for services rendered to any dependants of the optometrist, to his or her employer or practice partner or any dependants of the employer or partner

A 'dependant' person is a spouse or a child. The following provides definitions of these dependant persons:

a spouse, in relation to a dependant person means:

(a) a person who is legally married to, and is not living, on a permanent basis, separately and apart from, that person; and

(b) a de facto spouse of that person.

a child, in relation to a dependant person means:

(a) a child under the age of 16 years who is in the custody, care and control of the person or the spouse of the person; and

(b) a person who:

(i) has attained the age of 16 years who is in the custody, care and control of the person of the spouse of the person; or

(ii) is receiving full time education at a school, college or university; and

(iii) is not being paid a disability support pension under the Social Security Act 1991; and

(iv) is wholly or substantially dependent on the person or on the spouse of the person

O.5. SCHEDULE FEES AND MEDICARE BENEFITS

Medicare benefits are based on fees determined for each optometrical service. The services provided by optometrists which attract benefits are set out in the Health Insurance (General Medical Services Table) Regulations (as amended).

If the fee is greater than the Medicare benefit, optometrists are to inform the patient of the Medicare benefit payable for the item at the time of the consultation and that the additional fee will not attract benefits.

Medicare benefits are payable at 85% of the Schedule fee for services rendered.

Medicare Safety Nets